One of the most urgent and pressing needs in regards to Medicare Part D is effective education and outreach to people who do not speak English. In California’s diverse state, this is a large population. Close to 40% of Californians speak a language other than English at home and 20% of this population (6-7 million people) has limited English proficiency (LEP). Among California’s one million dually eligible alone, approximately one in five people have limited English proficiency. For these people, when a language barrier is added on top of Part D’s complexity that already presents significant access problems for many elderly and people on Medicare with a disability, navigating the program is almost impossible.
Indeed, California Health Advocates’ Sacramento office has witnessed this struggle on numerous occasions. One staff member, Marta Erismann, who is also a Health Insurance Counseling & Advocacy Program (HICAP) counselor, has personally assisted over 300 Spanish-speaking clients in the past few months, many of whom do not understand Part D and were neither able to communicate with their plans nor their pharmacists. Some of the problems reported include:
- Plans not having bilingual representatives, or if they did, the number of bilingual staff was limited and unable to respond to the demand.
- Being put on hold for hours waiting to speak to a Spanish-speaking representative, only to eventually be disconnected. Several clients with prepaid minutes for the cell phones quickly saw their minutes drain away as they waited, eventually being unable to call others for help.
- Being told numerous times to “call back in one hour” on several continuous days.
- Only being able to leave voicemail messages for plans, many that went unreturned for two or more weeks.
- Being unable to understand why their drugs were not covered at the pharmacy due to lack of bilingual staff.
According to some reports, these types of problems have marginally improved since the beginning of Part D. Some plans have gone beyond minimum requirements and do provide translation services in languages other than Spanish. Other plans also contract with interpretation services to field incoming non-English calls. Yet despite this improvement in some plans, serious problems continue to persist in many others. These problems persist despite Medicare’s Part D rules that plan call centers must be able to “accommodate” non-English speaking/reading beneficiaries and have appropriate staff and translation services available to do so. In addition, the Centers for Medicare and Medicaid Services (CMS) marketing guidance says that plans must make marketing materials available in any language that is the primary language of more than 10 percent of a plan’s geographic service area. In California, many plans continue to interpret this to mean only Spanish, leaving out other larger communities, such as Asian Pacific Islanders. For example, according to census data compiled by the Modern Language Association between six and twenty-one percent of the population in parts of Solano and San Mateo counties speak Tagalog. In parts of San Francisco county between seven and eighteen percent of the population speaks Chinese; and in parts of Santa Clara and Orange County, up to five percent speak Vietnamese.
CMS’ 10 percent benchmark is much looser than California’s five percent level required for some state programs, a move that ensures marketing and outreach caters to many more languages. Recently California passed a new law (SB 853) which requires HMOs to provide language assistance services at the hospitals and doctors’ offices they contract with for patients who speak limited or no English. It also requires plans to translate written materials, including letters and eligibility notices, into a patient’s primary language. Unfortunately SB 853 is just a state law and federal law in general supersedes the state. While SB 853 could potentially have a trickle-down effect on Part D plans in California, it is unlikely given the history of Medicare HMO plans’ unresponsiveness to other language access requirements passed in California.
With the challenges people with LEP meet in regards to their drug plans, CMS materials, and assistance (or lack thereof) from 1-800 Medicare, beneficiary advocates must do their best in their education and outreach efforts to these populations. In talking with several HICAP Program Managers throughout the state, below is a list of helpful, economical, and successful outreach/education strategies that HICAPs, service providers, advocacy organizations, and others working with LEP individuals can use. This list of ideas is meant to act as a catalyst for more creative solutions. If you or your agency/organization have additional ideas/strategies that you’d like to share, please contact Karen Fletcher.
General Tips on Successful Education/Outreach to LEP Communities
- Hire more bilingual staff. When trained staff also speak the language of the community they are working in, building trust is much easier.
- Offer differential pay to employees who speak more than one language.
- Job-sharing resources for language services – can train bilingual staff from other agencies in your organization’s area of expertise and pay for the hours they assist you and your LEP clients. For example, the HICAP in Kern County has trained bilingual staff at the county’s Area Agency on Aging Information and Referral office to also assist them with LEP Medicare beneficiaries.
- Hire interpreters for educational presentations/outreach events. The Santa Cruz County HICAP office has successfully used interpreters from Interpreters Unlimited. This organization has over 5,000 interpreters throughout California offering assistance in over 115 different languages. Another excellent interpretation/translation resource for the San Francisco bay area is Language 411, a part Family Bridges, Inc. For additional resources, see the end of last edition’s article on language access issues.
- Establish relationships and working collaborations with organizations serving various non-English speaking communities. Several HICAP programs have recruited excellent bilingual volunteers this way as well.
- Establish relationships with local ethnic media outlets.
- New America Media – Working nationwide, NAM’s multicultural, multilingual advertising services focus on working with and using ethnic media as a means of reaching various ethnic populations.
- Media Alliance– a 30 year-old media resource and advocacy center for media workers, non-profit organizations, and social justice activists. They have a publication with the contacts of both mainstream and ethnic media outlets in Northern California.
- Univision Communications, Inc. – a major Spanish-speaking media outlet – internet and TV
Tips Specific to Educational Presentations
- Know your audience – do your research beforehand, establish ties with other community services agencies, social workers, and community organizations serving the population to whom you are giving presentations.
- Spend time in the community, with the people you are presenting to. Arrive on site half an hour early and enjoy some coffee or tea with the people. Or stay afterwards for lunch. Join the community on a volunteer day or other community activity.
- Keep presentations short and simple, light and educational. One HICAP Program Manager suggests keeping presentations to 20 minutes or less.
- Use stories that draw from people’s daily experiences.
- Ask questions; have the audience participate as much as possible.
- Use visuals. Fresno County’s HICAP Program Manager uses flip charts and large Medicare, Medi-Cal and HMO cards that she’s created as effective visuals. Contra Costa County’s Program Manager does role-plays with different hats, acting out various insurance scenarios for different clients. Such creative use of visuals makes presentations more fun, understandable, and easier for people to remember important information.
Meeting the language needs of California’s diverse communities is of growing concern and great importance. By working creatively, sharing our resources, and advocating for more legislation in this area, we can successfully reach and assist California’s LEP populations.